Does Q5120 require prior authorization?

Yes, Q5120 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for Q5120?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`Q5120`, Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

This article provides billing and coding guidelines that complement Local Coverage Determination (LCD) L37176 for White Cell Colony Stimulating Factors; refer to LCD L37176 for specific coverage criteria, indications, and limitations.

Documentation of a prior, medically necessary allogeneic bone marrow transplantation or peripheral stem cell transplantation (e.g., transplant operative report, discharge summary, transplant center records).

Clinical documentation supporting the indication for DLI (diagnosis/problem list with corresponding ICD-10 code among covered diagnoses such as C91.00-C91.02, C92.00-C92.02, C92.10-C92.12, or documentation of transplant status Z94.81 / Z94.84).

Medical records demonstrating that the requested DLI is not one of the policy-listed experimental/investigational uses (e.g., not CAR-modified donor lymphocytes, not G-CSF-stimulated DLI for the purpose stated, not intrathecal DLI, not ECP-treated donor cells for pre-transplant organ tolerance, etc.).

If applicable, documentation of prior treatments and rationale for DLI as salvage therapy or for graft-versus-leukemia effects (e.g., prior relapse after allo-HCT, prior therapies tried and outcomes).

Key Coverage Criteria

Medically necessary use of Leukine, Neupogen, Nivestym, Nypozi, Releuko, and Zarxio for bone marrow/stem cell transplant indications when: (a) non-myeloid malignancies with myeloablative chemotherapy followed by BMT; or (b) mobilization of hematopoietic progenitor cells into peripheral blood for leukapheresis; or (c) PSCT after myeloablative chemotherapy.
ICD-10 codes covered if selection criteria are met: Z94.84 (Stem cells transplant status).
ICD-10 codes covered if selection criteria are met: C92.10 - C92.12 (Chronic myeloid leukemia, BCR/ABL-positive).
ICD-10 codes covered if selection criteria are met: Z94.81 (Bone marrow transplant status).
Donor lymphocyte infusion (DLI) is considered medically necessary for persons who have a prior, medically necessary allogeneic bone marrow or peripheral stem cell transplantation.
DLI for treatment/management related to the following covered ICD-10 diagnoses when selection criteria are met: C91.00 - C91.02 (Acute lymphoblastic leukemia [ALL]).

14 Active Policies

BCBSNJ-DRUGS-012-E7C32F18C6, Granulocyte Colony Stimulating Factor (G-CSF - Neupogen, Neulasta, Granix, Zarxio, Fulphila, Nivestym, Udenyca, Ziextenzo, Nyvepria) and Granulocyte-Macrophage Colony Stimulating Factor (GM-CSF - Leukine)

MODA-PEGFILGRASTIM-894B6C2794, Long-Acting Granulocyte Colony Stimulating Factors (LA-GCSF): Fulphila; Fylnetra; Neulasta; Nyvepria; Pegfilgrastimfpgk; Rolvedon; Ryzneuta; Stimufend; Udenyca; Ziextenzo

BCBSTN-19ec4a9011, Pegfilgrastim (Neulasta); Pegfilgrastim-jmdb (Fulphila); Pegfilgrastim--pbbk (Fylnetra); Pegfilgrastim- apgf (Nyvepria); Pegfilgrastim-fpgk (Stimufed); Pegfilgrastim-cbqv (Udenyca); Pegfilgrastim-bmez (Ziextenzo)

A56748, Billing and Coding: White Cell Colony Stimulating Factors

UHC-POL-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

AETNA-CPB-0638, Donor Lymphocyte Infusion

BCBSIL-RX502.061, Oncology Medications

BCBSMT-RX502.061, Oncology Medications

BCBSNM-RX502.061, Oncology Medications

BCBSOK-RX502.061, Oncology Medications

UMR-POL-UMR-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

EVICORE-HPLAN-CIGNA-729A536F50C8, Q3 - 2026 Cigna MedOnc Master Drug List.pdf

SUREST-POL-SUREST-white-blood-cell-colony-stimulating-factors, White Blood Cell Colony Stimulating Factors

EVICORE-HPLAN-HEALTH_PARTNERS_PLANS-4BC80209CCC5, Q3 - 2026 Jefferson Health Plans MedOnc Master Drug List

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Q5120, Injection, pegfilgrastim-bmez (ziextenzo), biosimilar, 0.5 mg